Risk Management and Healthcare Policy Dovepress open access to scientific and medical research

Open Access Full Text Article ORIGINAL RESEARCH Health Centers’ Preparedness for Coronavirus (COVID-19) Pandemic in , , 2020

This article was published in the following Dove Press journal: Risk Management and Healthcare Policy

Fanos Yeshanew Ayele Background: COVID-19 is a highly contagious respiratory disease caused by severe acute Aregash Abebayehu Zerga respiratory syndrome coronavirus two (SARS-CoV-2). Preparedness of health facilities to prevent Fentaw Tadese the spread of COVID-19 is an immediate priority to safeguard patients and healthcare workers and to reduce the spread of the pandemic. However, the preparedness of health centers in south Wollo School of Public Health, College of Medicine and Health Sciences, Wollo zone is unknown. University, , Ethiopia Objective: To assess the preparedness of Health Centers for COVID-19 in South Wollo Zone, Ethiopia, 2020. Methods: Health facility-based cross-sectional study was conducted among forty-six Health Centers in South Wollo zone in August 2020. The sampled health centers were selected by lottery method. The data was collected from the manager of the health centers using a pretested interviewer-administered and observational checklist. The ReadyScore criteria was used to classify the level of preparedness, in which health centers with a score of >80%, 40–80%, and <40% were considered as better prepared, work to do, and not ready, respectively. Results: In this study, the median score of health centers preparedness for COVID-19 was 70.3 ± 21.6 interquartile ranges with a minimum score of 40.5 and the maximum score of 83.8. Only 12 (26.1%) of the health centers were prepared for the COVID-19 pandemic. The majority (73.9%) of the health centers were found within the group of “work to do”. Conversely, none of the health centers were found within the “not ready” or below group. Conclusion: This study concluded that the preparedness status of the majority of health centers in South Wollo Zone was within the “work to do” group. Therefore, the local government and other concerned bodies should monitor and support health centers to increase their preparedness and to build their capacity. Keywords: COVID-19, preparedness, health centers, South Wollo Zone, Ethiopia

Introduction Coronavirus Disease 2019 (COVID-19) is a highly transmittable respiratory disease caused by severe acute respiratory syndrome coronavirus two (SARS-CoV-2). It is transmitted mostly by contact with infectious material that is projected during sneezing or coughing of infected patients.1 It has the most common symptoms of fever, dry cough, shortness of breath, and tiredness, and less common symptoms of loss in taste and smell, sore throat, headache, diarrhea, aches, pains, and may Correspondence: Aregash Abebayehu progress to pneumonia and respiratory failure.2 It was first reported from Wuhan Zerga 3 Email [email protected] City, China in December 2019 and now spread at alarming rates all over the world. submit your manuscript | www.dovepress.com Risk Management and Healthcare Policy 2021:14 887–893 887 DovePress © 2021 Ayele et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php http://doi.org/10.2147/RMHP.S290135 and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Ayele et al Dovepress

Until October 31, 2020, over 46 million confirmed cases recognized as critical to shift the pandemic. However, after and 1.19 million deaths were reported in the world.4 In the onset of the COVID-19, quantitative data on the pre­ Africa, since February 14, 2020, when the first case was paredness of health facilities for covid-19 is limited. Even reported, above 1.8 million cases, and 42,630 deaths were though a study was conducted on health systems adapt­ recorded.5 In Ethiopia from March 13, when the case was ability in Ethiopia, it was not published in a peer-reviewed first detected, until October 31, 2020, a total of 95,789 journal and was conducted by including only 9.8% of the cases and 1, 464 deaths, were reported.6 national health centers.16 Hence, assessing healthcare Due to its infection and rapid transmission, the World facilities’ preparedness is a high priority.17 Therefore, Health Organization (WHO) was declared a Public Health this study aimed to assess health centers preparedness Emergency of International Concern and characterized it towards COVID-19 pandemic which helps to prioritize 7 as a pandemic. In Ethiopia to mitigate the COVID-19 supports to health centers with significant gaps in pandemic, the laboratory test, and treatment centers were preparedness. extended to regions, zones, and district levels. Physical distancing, hand hygiene, and mask-wearing were highly promoted through media by using drama, music, and pos­ Methods ters. For physical distancing to be maximally implemen­ Study Design and Setting ted, schools of all levels were closed; religious gatherings Health facility-based cross-sectional study design was car­ were limited and transport across cities was banned. ried out in August 2020. The study was conducted among The prevention measures include heightened surveil­ the Health centers of South Wollo zone, , lance and rapid identification of suspected cases, followed Ethiopia. It is one of the 11 Zones of the Amhara regional by patient transfer and isolation, rapid diagnosis, tracing, state of Ethiopia. It is bordered on the south by North and follow-up of potential contacts.8 The ability to control Shewa, on the west by East Gojjam, on the northwest by local transmission depends on the application of principles South Gondar, on the north by North Wollo, on the north­ of rapid identification, prevention, and control, followed east by Afar Region, and on the east by the special by patient isolation, rapid diagnosis, and contact tracing.9 Zone and Argobba special district. Towns and cities in the The WHO has already developed a global COVID-19 south Wollo zone include Dessie, , Haik, strategic preparedness and response plan, which aims to , Akesta, and Mekaneselam and it has 22 districts. support countries to accelerate the development of their The capital city of south Wollo zone is Dessie town which capacity to prevent, detect, and respond to any potential is located 401 km north of Addis Ababa the capital of COVID-19 outbreak.10 Ethiopia developed the national Ethiopia. According to zonal health Department data, comprehensive COVID-19 management handbook interim a total of 135 health centers are found in the zone. guideline for healthcare settings, healthcare facility COVID-19 preparedness and response protocol and the Sample Size and Sampling Technique ministry of health essential care services guideline during In south Wollo zone, there are 135 health centers. From COVID-19.11,12 these, 46 (34%) health centers were selected by lottery The preparedness level of countries or organizations to method for this study. prevent an emergency was classified using the ReadyScore criteria created by the “resolve to save lives”.13 The score determines whether a country is prepared to find, stop, and Data Collection and Control prevent epidemics, using data from the WHO’s Joint The data was collected from the manager of health centers. External Evaluation (JEE).14 Based on this criteria, coun­ A pre-tested interviewer-administered checklist and obser­ tries are classified into five levels; better prepared (over vation checklist adapted from the WHO and Centers for 80%), work to do (40–80%), not ready (under 40%), in Disease Control (CDC) was used to collect the data progress, and unknown.13 Before the onset of COVID-19, (Appendix 1).18,19 Before the actual data collection, the the preparedness of Ethiopia for an emergency was checklist was pretested on 5% (2 health centers) of the 52%.14,15 This means there is a potential for lives to be sample size at Oromia special zone, Amhara region. The lost if a new health threat emerges in the country. The data was collected using the local language, Amharic by preparedness of health facilities for COVID-19 response is two trained public health officers. The completeness of the

888 submit your manuscript | www.dovepress.com Risk Management and Healthcare Policy 2021:14 DovePress Dovepress Ayele et al collected data was checked by the supervisor and the Result principal investigators. Description and Preparedness of the Health Centers Operational Definition About one third (34.8%) of the health centers were from Preparedness the urban area. The median score of preparedness for A total of 37 (yes or no) questions were used to compute COVID-19 was 70.3 ±21.6 interquartile ranges, with the preparedness. Responses to these questions were a minimum and maximum score of 40.5 and 83.8, respec­ summed and converted into percent. Then, based on the tively. When categorized by the ReadyScore cut-offs, only ReadyScore criteria of preparedness; health centers were 12 (26.1%) of the health centers were prepared for the classified as “better prepared” if they scored over 80%, pandemic (scored over 80%). Majority (73.9%) of the “work to do” if scored 40 to 80%, and “not ready” if health centers were found within the group of “work to 13 scored less than 40%. do”. Conversely, none of the health centers was found within the “not ready” or below group. Data Management and Analysis The collected data were entered into Epi-Data version Coordination, Communication, and 3.1 and exported to the Statistical package for social Reporting System of the Health Centers science (SPSS) version 23 for cleaning and analysis. All health centers had Infection Prevention and Control The reliability of the questions was checked by (IPC) focal persons. The majority (91.2%) and 44 (95.7%) Cronbach’s Alpha (α= 0.72). The response of indivi­ of health centers had IPC guidelines and emergency dual variables was coded as yes =1 and no = 0 response plans for COVID-19, respectively. Above half (Appendix 2). To calculate the preparedness of each (78.3%) of the health centers had a focal person and an health center, the response of individual variables was emergency committee for COVID-19 (Table 1). summed and converted into percent. Once the value of preparedness was converted into percent, normality was checked with histogram and it was not normally Personal Protective Equipment (PPE) distributed. Hence, the median ± interquartile range of Supplies in the Health Centers preparedness was calculated. To classify health centers Above half 28 (60.9%) of the health centers perform PPE based on the ReadyScore criteria, the calculated inventory at least once a month. Only 10 (21.7%) and 22 preparedness percent of each health center was trans­ (47.8%) of the health centers had sufficient quantity and formed into categories. Descriptive statistics were com­ good quality PPE in store. Only the healthcare workers of puted and reported in frequencies and percentiles. 16 (34.8%) health centers had access to gowns, gloves, Results were presented using tables and texts. face masks, and eye protection for conducting physical evaluations of patients with respiratory symptoms Ethical Consideration (Table 2). This study was conducted in accordance with the Declaration of Helsinki. Ethical clearance was obtained Training, Triage, and Evaluation of from the Institutional Review Committee of Wollo Suspected COVID-19 Cases University, College of Medicine and Health Sciences. All healthcare workers (HCW) who evaluate or treat sus­ A permission letter was gained from the South Wollo pected and confirmed COVID-19 patients were trained in zone Health Office, Dessie. Informed consent was taken standard and transmission-based precautions of COVID- from the manager of each health center after the purpose 19. The majority 36 (78.3%) of HCWs and supportive staff and objectives of the study had been informed. They were were trained in recognition of COVID 19, and 36 (78.3%) informed that involvement in the study was voluntary. The of the health centers had a physical barrier between name of the health centers was not included in the report. patients and workers (Table 3).

Risk Management and Healthcare Policy 2021:14 submit your manuscript | www.dovepress.com 889 DovePress Ayele et al Dovepress

Table 1 Coordination, Communication, and Reporting System of Health Centers in South Wollo Zone, Ethiopia, 2020

Variables Yes No Frequency Frequency (%) (%)

The facility has an IPC focal person in place 46 (100) –

The facility has an IPC guideline 42 (91.3) 4 (8.7)

Training of IPC focal person at least once a year 22 (47.8) 24 (52.8)

The facility has an emergency response plan for COVID-19 44 (95.7) 2 (4.3)

The facility has an emergency committee that meets at least every week to discuss planning for and/or 36 (78.3) 10 (21.7) response to COVID-19

The facility has designated a focal person(s) for COVID-19 cases 36 (78.3) 10 (21.7)

HCWs have been given phone number(s) for the focal person(s) to report suspected or confirmed COVID19 38 (82.6) 8 (17.4) cases

COVID-19 focal person(s), facility leadership, and/or emergency committee know public health authorities at 38 (82.6) 8 (17.4) the national or subnational level to report suspected or confirmed COVID-19 cases

COVID-19 focal person(s) and facility leadership know national or sub-national guidance for referring patients 42 (91.3) 4 (8.7) with suspected or confirmed COVID-19.

Table 2 Personal Protective Equipment (PPE) Supplies System in Health Centers of South Wollo Zone, Ethiopia, 2020

Variables Yes No Frequency Frequency (%) (%)

The facility performs an inventory of PPE supply at least once a month 28 (60.9) 18 (39.1) PPE available in sufficient quantity 10 (21.7) 36 (78.3) PPE available in good quality 22 (47.8) 24 (52.2) A person responsible for managing the supply chain for critical IPC supplies has been identified 36 (78.2) 10 (21.7) Facility leadership knows how to request additional supplies from national or sub-national authorities 42 (91.3) 4 (9.7)

Additional considerations for supplies in locations with community transmission

The facility has performed an inventory of PPE supplies in the past 7 days 20 (43.5) 26 (56.5)

The facility has the following supplies in stock in any amount at the time of the assessment

Non-sterile gloves 34 (73.9) 12 (26.1) Gowns 16 (34.8) 30 (65.2) Eye protection (face shields or goggles) 16 (34.8) 30 (65.2) Face masks 36 (78.3) 10 (21.7) Alcohol-based hand rub 44 (95.5) 2 (4.3) Soap 42 (91.3) 4 (8.7) Disinfectants (eg, sodium hypochlorite) 42 (91.3) 4 (8.7) HCWs conducting physical evaluations of patients with respiratory symptoms have access to gowns, gloves, 16 (34.8) 30 (65.2) face masks, and eye protection

Discussion nearly in every community and can be the potential area This study aimed to assess the preparedness and response for the transmission of COVID-19 unless a proper preven­ level of south Wollo zone health centers in confronting the tion system is established.20 Preparedness of the healthcare spread of the COVID-19 pandemic. Health centers are facilities to prevent the transmission of COVID-19 is an

890 submit your manuscript | www.dovepress.com Risk Management and Healthcare Policy 2021:14 DovePress Dovepress Ayele et al

Table 3 Training, Triage, and Evaluation of Suspected COVID-19 Cases Among Health Centers of South Wollo Zone, Ethiopia, 2020

Variables Yes No Frequency Frequency (%) (%)

All HCWs (including clinical and support staff) are trained in recognition of COVID-19 symptoms 36 (78.3) 10 (21.7)

HCWs who were working in areas evaluating or treating patients with suspected and confirmed COVID-19 46 (100) – are trained in standard and transmission-based precautions in the context of COVID-19

The facility is implementing alternative ways for patients seeking care with respiratory symptoms to 31 (67.4) 15 (32.6) communicate before presenting to the facility, such as a telephone.

Signs or posters directing patients with respiratory symptoms to proceed directly to the registration desk are 24 (52.2) 22 (47.8) posted at all facility entrances

A physical barrier is in place between staff and patients presenting to the registration desk (for example, 36 (78.3) 10 (21.7) a plastic/glass window or table providing at least 1-meter separation)

The facility has created a separate area for patients presenting with acute respiratory symptoms (the 26 (56.5) 20 (43.5) “respiratory waiting area”)

A well ventilated private area available for physical examination of patients with ARS. 20 (43.5) 26 (56.5)

Benches, chairs, or other seating in the respiratory waiting area is separated by at least 1 meter 28 (60.9) 18 (39.1)

Functional hand hygiene stations(soap and water) are available near the registration desk and in the respiratory 36 (78.3) 10 (21.7) waiting area

Alcohol-based hand rub easily available 44 (95.7) 2 (4.3)

Dedicated toilets are available for patients in the respiratory waiting area Single rooms with doors are available – 46 (100) for the physical evaluation of patients with respiratory symptoms

COVID-19 triage and flow chart are available for HCWs evaluating patients in the respiratory waiting area 26 (56.5) 20 (43.5)

Dedicated Person (HCW) at the entry to order patients 34 (73.9) 12 (26.1)

Isolation center available for suspected or confirmed cases of COVID-19 36 (78.3) 10 (21.7) immediate priority to safeguard patients and healthcare In the current study, only one in five health centers was workers, protect risk groups, reduce the demand for spe­ prepared for the pandemic and the rest were found within cialized healthcare, and to minimize the spread of the the “work to do” category of the preparedness pandemic to other healthcare facilities and the wider ReadyScore. It is supported by the national study which community.21 stated that there is a disparity in the levels of In this study, the median preparedness score of the preparedness.16 This might be due to differences in set­ health centers for COVID-19 was 70.3±21.6. It was con­ tings in which urban health centers prepared better than sistent with the mean score of preprint research conducted the rural health centers due to fear of exposure.22 on the health systems adaptability at primary level care for The WHO interim guidance developed five IPC strate­ COVID-19 in Ethiopia, which was 73.1±16.1.16 However, gies needed to prevent or reduce the transmission of the study findings were below the ReadyScore cutoff point COVID-19 in healthcare facilities. These are screening for better prepared (>80%) which implies that much work and triage, applying standard precautions for all patients, is expected from the country as well as from the local implementing additional precautions, implementing government.13 As most health centers operate on tight administrative controls, and implementing environmental budgets, they may not have the financial reserves to pre­ and engineering controls. The guidance stated that screen­ pare well for an emergency like the COVID-19 ing all persons at the first point of contact with the health- pandemic.20 care facility is critical to allow for early recognition and

Risk Management and Healthcare Policy 2021:14 submit your manuscript | www.dovepress.com 891 DovePress Ayele et al Dovepress immediate isolation.23 But in this study, only 56% of the draft, substantially reviewing, and editing the manuscript. health centers had a well-equipped triage. And all authors have reviewed and agreed on all versions Effective use of PPE is considered as one of the meth­ of the article before submission and during revision; ods for preventing the spread of COVID-19 to and from agreed on the journal to which the article will be sub­ healthcare providers and patients. In this study, only mitted; and agree to take responsibility and be accountable 21.7% of health centers have an adequate amount of PPE for the contents of the article. at the store. It was supported by studies conducted on the availability of PPE in South America, and Addis Ababa in Funding which only 21.8% and 23% of the hospitals have an There is no funding to report. adequate amount of PPE, respectively.24,25 Further, a study from the hospitals of North Shewa zone, Ethiopia reported that the availability of PPE was 29.5%.26 A study Disclosure from Nigeria reported that only 34.4% of health profes­ The authors declared that they have no conflicts of interest sionals used face masks while consulting patients with for this work. respiratory symptoms.27 This showed that healthcare sys­ tems had shocked by a shortage of PPE. This might be References because the government gives high priority to COVID-19 treatment centers. 1. WHO. Modes of Transmission of Virus Causing COVID-19: Implications for IPC Precaution Recommendations: Scientific Brief, 27 March 2020. World Health Organization; 2020. Conclusion 2. Struyf T, Deeks JJ, Dinnes J, et al. Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings In conclusion, the preparedness status of the majority of has COVID-19 disease. Cochrane Database Syst Rev. 2020;7. health centers in South Wollo Zone was within the “work 3. WHO. Coronavirus Disease 2019 (COVID-19) Strategic to do” group. Therefore, the local government and other Preparedness and Response Plan: Accelerating Readiness in the Eastern Mediterranean Region: February 2020. World Health concerned bodies like sponsoring organizations should Organization. Regional Office for the Eastern Mediterranean; 2020. monitor and support health centers to increase their pre­ 4. World health data platform explore WHO’s key data tools, data sets paredness and to build their capacity. and databases. Available from: https://www.who.int/data. Accessed October 31, 2020. 5. Africa WROf. WHO Ramps Up Preparedness for Novel Coronavirus Abbreviation in the African Region. 2020. 6. Ting DSW, Carin L, Dzau V, Wong TY. Digital technology and COVID-19, coronavirus disease 2019; HCW, healthcare COVID-19. Nat Med. 2020;26(4):459–461. doi:10.1038/s41591- worker; IPC, infection prevention and control; JEE, Joint 020-0824-5 External Evaluation; PPE, personal protective equipment; 7. Sohrabi C, Alsafi Z, O’Neill N, et al. World Health Organization declares global emergency: a review of the 2019 novel coronavirus WHO, World Health Organization. (COVID-19). Int J Surg. 2020;76:71–76 8. Jee Y. WHO international health regulations emergency committee for the COVID-19 outbreak. Epidemiol Health. 2020;42:e2020013. Data Sharing Statement doi:10.4178/epih.e2020013 All the required data has been included in the manuscript. 9. Gilbert M, Pullano G, Pinotti F, et al. Preparedness and vulnerability of African countries against importations of COVID-19: a modelling study. Lancet. 2020;395(10227):871–877. doi:10.1016/S0140- Consent for Publication 6736(20)30411-6 Consent for publication is secured from study participants. 10. WHO. Critical Preparedness, Readiness and Response Actions for COVID-19: Interim Guidance, 22 March 2020. World Health Organization; 2020. Acknowledgments 11. Ethiopia MoH. Infection prevention and control interim protocol for We would like to thank data collectors, the managers of COVID-19 in health care settings in Ethiopia. April, 2020. Available from: https://www.ephi.gov.et/images/EPHI_PHEOC_COVID-19_ Health Centers as well as South Wollo zone health office IPC_Interim_Guideline%20_Eng.pdf. Accessed January 5, 2021. for their cooperation. 12. Baye K. COVID-19 Prevention Measures in Ethiopia: Current Realities and Prospects. Vol. 141. Intl Food Policy Res Inst; 2020. 13. ReadyScore/resolve to save lives. Available from: https://resolvetosa Author Contributions velives.org/prevent-epidemics/readyscore. Accessed October 29, FY, AA, and FT have participated in the conception, study 2020. 14. WHO. Joint External Evaluation of IHR Core Capacities of the design, execution, data acquisition, investigation, super­ Federal Democratic Republic of Ethiopia: Mission Report, vision, formal analysis, interpretation, writing the original March 2016. World Health Organization; 2017.

892 submit your manuscript | www.dovepress.com Risk Management and Healthcare Policy 2021:14 DovePress Dovepress Ayele et al

15. Ethiopia overview/prevent epidemics. Available from: https://preven 22. Blanchet K, Nam SL, Ramalingam B, Pozo-Martin F. Governance tepidemics.org/countries/eth/?section=data#country-strengths-gaps. and capacity to manage resilience of health systems: towards a new Accessed September 23, 2020. conceptual framework. Int J Health Policy Manag. 2017;6(8):431. 16. Abebe Y, Beshir IA, Tsegaye ZT, et al. Health system adaptability at doi:10.15171/ijhpm.2017.36 primary level care in the time of COIVD-19: experiences from 23. WHO. Infection Prevention and Control Guidance for Long-Term Ethiopia. 2020. Care Facilities in the Context of COVID-19: Interim Guidance, 17. Sharma SK, Sharma N. Hospital preparedness and resilience in pub­ 21 March 2020. World Health Organization; 2020. lic health emergencies at district hospitals and community health 24. Deressa W, Worku A, Abebe W, Gizaw M, Amogne W. Availability centres. J Health Manag. 2020;22(2):146–156. doi:10.1177/ of personal protective equipment and satisfaction of healthcare pro­ 0972063420935539 fessionals during COVID-19 pandemic in Ethiopia. medRxiv. 2020. 18. Centers for Disease Control and Prevention. Facility Readiness 25. Martin-Delgado J, Viteri E, Mula A, et al. Availability of personal Assessment for Coronavirus Disease 2019 (COVID-19). Infection protective equipment and diagnostic and treatment facilities for Prevention and Control Considerations in Non-US Healthcare healthcare workers involved in COVID-19 care: a cross-sectional Settings. CDC. 2020. Available from: https://www.cdc.gov/corona study in Brazil, Colombia, and Ecuador. PLoS One. 2020;15(11): virus/2019-ncov/downloads/healthcare-facility-readiness-assessment. e0242185. doi:10.1371/journal.pone.0242185 pdf. Accessed February 25, 2021. 26. Mulu GB, Kebede WM, Worku SA, Mittiku YM, Ayelign B. 19. WHO. Hospital Readiness Checklist for COVID-19 Interim Version Preparedness and responses of healthcare providers to combat the February 24 2020. World Health Organization. Regional Office for spread of COVID-19 among North Shewa Zone Hospitals, Amhara, Europe; 2020. Ethiopia, 2020. Infect Drug Resist. 2020;13:3171. 20. Burse N, Thompson E, Monger M. The role of public health in 27. Umar SS, Muhammad BO, Zaharadeen SB. Preparedness of Nigerian COVID-19 emergency response efforts from a rural health health institutions toward managing lassa fever epidemic and perspective. PCD Staff. 17:E70. 2020. Covid-19 pandemic. Niger J Med. 2020;29(2):303. doi:10.4103/ 21. European Centre for Disease Prevention and Control. Infection pre­ NJM.NJM_71_20 vention and control and preparedness for COVID-19 in healthcare settings - fifth update. 6 October 2020. ECDC. Stockholm; 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/docu ments/Infection-prevention-and-control-in-healthcare-settings- COVID-19_5th_update.pdf. Accessed February 25, 2021.

Risk Management and Healthcare Policy Dovepress Publish your work in this journal Risk Management and Healthcare Policy is an international, peer- guidelines, expert opinion and commentary, case reports and reviewed, open access journal focusing on all aspects of public extended reports. The manuscript management system is completely health, policy, and preventative measures to promote good health online and includes a very quick and fair peer-review system, which and improve morbidity and mortality in the population. The journal is all easy to use. Visit http://www.dovepress.com/testimonials.php welcomes submitted papers covering original research, basic to read real quotes from published authors. science, clinical & epidemiological studies, reviews and evaluations,

Submit your manuscript here: https://www.dovepress.com/risk-management-and-healthcare-policy-journal

Risk Management and Healthcare Policy 2021:14 submit your manuscript | www.dovepress.com 893 DovePress